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provisionally made using ultrasound, and finally confirmed by the pathologist after removal at laparotomy.
The presence of the fetus merely complicates a well
worked out diagnostic route.
Early pregnancy
As a general rule, unless there is considerable evidence
of the presence of a malignancy, or the ovarian mass is
undergoing some mechanical problem, surgery should
be avoided in the first trimester. Most ovarian masses
are corpora lutea; ultrasound should be used to determine whether there are solid or cystic areas present and
to monitor changing size of the mass. However, the surgeon should remember that the corpora lutea may continue to grow to a large size under the influence of the
gonadotropins.
Mid and late pregnancy
Once the pregnancy is maintaining itself independently
of the ovaries, management of ovarian masses can
safely be more aggressive. However, if there is a possibility at any time in gestation of a malignancy being
present, a laparotomy should be performed.
If, when the abdomen is opened, there is evidence of
a cancer of the ovaries the standard management of
total abdominal hysterectomy, bilateral ovariotomy
and omentectomy should be performed, the pregnancy
sacrificed if non-viable or delivered by Caesarean section and handed to the paediatricians if viable. The surgical management should be followed by appropriate
chemotherapy.
Mechanical obstruction is occasionally the method
of presentation of an ovarian mass which, until removed, must be looked upon with suspicion. This
problem usually arises later in pregnancy and is diagnosed in the course of investigating an unstable or unusual lie of the fetus. Ultrasound should be performed
and the characteristics of the mass determined. If the
fetus is viable an elective caesarean section should
be performed, followed by appropriate treatment.
When the cyst appears benign, it is removed and the
remaining pelvic organs preserved. If there is a suspicion of malignancy, the procedure outlined above is
performed.
Symptomatic presentation due to torsion, rupture or
haemorrhage into the cystic mass will occur from time
to time. This should be treated as an acute episode and,
cervix. It may be necessary to perform an emergency
radical hysterectomy if the haemorrhage cannot be
controlled; the patient’s life is at serious risk.
Carcinoma of the vulva
As this is predominantly a problem of the older woman,
the mean age in the editor’s series of over 270 cases
being 68 years, it is rarely seen in pregnant women. The
editor has seen one case developing in a 26-year-old
woman and presenting at 20 weeks’ gestation. This was
successfully dealt with, utilizing the three-incision technique of radical vulvectomy and bilateral groin node
dissection (see Chapter 13).
Pregnancy does not seem to have any bearing on the
course of the disease.
The editor has experience of another patient in his
series who has gone on after radical vulvectomy and
groin node dissection to become pregnant twice and
produce healthy children, albeit by Caesarean section.
The obstetrician, unfortunately, had other indications
for a surgical delivery. In general, there is no reason why
a vaginal delivery should not be performed.
Carcinoma of the vagina
As with carcinoma of the vulva, this is predominantly a
disease of women in later life, the mean age being 60
years. Rarely, the problem arises in young women and
may be of the clear cell carcinoma type; the editor has
experience of one such case presenting in a 20-year-old
patient at 18 weeks’ gestation. A radical hysterectomy
and pelvic node dissection was performed, sacrificing
the pregnancy; the carcinoma was lying in the posterior
fornix of the vagina. The patient is alive and well years
later.
Carcinoma of the ovary
The great majority of ovarian tumours complicating
pregnancy are benign, usually being corpora lutea.
Carcinoma of the ovary in pregnancy is very rare,
occurring in 1 in 10 000 pregnancies.
As with ovarian masses in the non-pregnant state, the
most important concern of the clinician is to make a
diagnosis. This is suggested at bimanual examination,
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lationship between the pregnancy and tumour growth, the
rare involvement of the fetus, and methods of preserving reproductive capacity.
References
Many of the references available relate to single cases or collected cases from major institutions. The student should initially turn his attention to the major review articles, such as
that in Surgical Disease in Pregnancy, Barber HRK, Graber
EA (eds), Philadelphia: W.B. Saunders, pp. 310–35.
Also, Lutz MH, Underwood PB, Rozier JC, Putney JW.
Genital malignancy in pregnancy. Am J Obstet Gynecol
1977;129:536–42.
unless delivery is imminent, a laparotomy performed
and the mass removed. If a diagnosis of carcinoma is
made later, the patient should be re-explored after delivery and the standard surgical management performed (see Chapter 20).
Further reading
Textbooks
JS Shepherd, in Chapter 16 of Clinical Gynaecological Oncology (1985) Shepherd and Monaghan (eds), Blackwell Scien-
tific, Oxford, has made a comprehensive review of the present
state of the subject. He has carefully commented on the rare re-
CANCERS COMPLICATING PREGNANCY
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272
Patient preparation
No special preoperative preparation is required,
although if the appendix is found to be inflamed
at laparotomy or there is evidence of free pus,
a Gram-negative-specific antibiotic should be given
intravenously during the procedure.
Anaesthesia
No special requirement is necessary, except for general
anaesthesia.
The operation
The incision
The appendix can be reached through most standard
gynaecological incisions and therefore there is no
special need to extend or alter the original wound.
However, it is very important that the edges of the
wound should not be soiled by contact with the appendix or the appendix stump when the appendix has been
removed. The surgeon should take precautions to cover
and screen the edges of the wound, and impress on the
assistants the need to keep the appendix clear at all
times.
Dividing the appendix mesentery
The appendix is elevated using the Babcock forceps,
putting the appendiceal mesentery on the stretch. In
thin patients, the small appendiceal artery can often be
visualized. A short, straight tissue clamp is placed
across the vessel with its tip close to the wall of the appendix (Fig. 26.1). Using scissors the mesentery is cut,
Operations on the intestinal tract for
the gynaecologist
26
It is rare for the gynaecological surgeon to be involved
with bowel surgery as part of routine gynaecological
surgery. However, he should be able to perform an
appendicectomy, and repair occasional small injuries
to the bowel created whilst separating adhesions. If he
has any doubt or if the primary pathology is gastrointestinal, the general surgeon should be called.
Appendicectomy
The question of whether to remove the appendix
at the time of laparotomy for pelvic disease remains
contentious. In British practice, the appendix is not
removed, except when it is found to be abnormal
on inspection. The appendix should always be
removed in cases of pseudomyxoma peritoneii as
this condition is often associated with tumours of
the appendix. The presence of faecoliths, mucoceles or
any signs of inflammation warrants its removal, provided that the extra operating time does not hazard the
patient. The major concern of the surgeon is the risk of
contaminating the clean peritoneal cavity with the contents of the appendix. It is vitally important that a technique should be used which reduces this risk to zero and
that the patient is given an appropriate prophylactic
antibiotic.
Instruments
The general set described in Chapter 2 will be in use; the
only addition which is required is a Babcock soft tissue
forceps and a fine 2.0 Vicryl suture on a round-bodied
atraumatic needle.
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leaving the appendix attached to the caecum solely by
its base. When the appendix is long, more than one
pedicle may be required.
Placing the purse-string suture
It is advantageous to place the purse-string suture
around the base of the appendix before it is removed as
this reduces the risk of contamination. The Vicryl
suture is now inserted in a series of bites around the
base of the appendix (Fig. 26.2), taking care not to
place them too close as this makes inversion difficult.
Removing the appendix
The base of the appendix is now crushed using a
straight clamp which is then replaced a short distance
down the appendix; a Vicryl tie is now placed around
the crushed part of the appendix and the ends left long
and held in a forceps (Fig. 26.3). The surgeon now cuts
across the appendix below the clamp and places it, and
the knife which has been contaminated by the bowel
contents, into a dish. (The scrub nurse removes this
from the operative field.)
Inversion of the appendix stump
As the surgeon cuts through the appendix the assistant
steadies the long tie in one hand and grasps the caecal
INTESTINAL TRACT OPERATIONS
273
Fig. 26.1 Dividing the appendix mesentery.
Fig. 26.2 Placing the purse-string suture.
Fig. 26.3 Removing the appendix.
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the procedure, resulting in clamps being placed on
bowel, or tears produced when adhesions are roughly
separated.
The major pathological factors involved in the development of traumatic injuries to the bowel are:
1 Endometriosis, particularly the chronic disease with
development of chocolate cysts of the ovary and multiple adhesions to tube uterus and bowel.
2 Pelvic inflammatory disease, particularly chronic
disease, where multiple adhesions may have developed.
3 Malignant disease, particularly ovarian carcinoma.
4 Infective disease of the bowel, such as acute appen-
dicitis, will also produce multiple adhesive problems
for the gynaecologist as the infection commonly drains
into the pelvis affecting tubes and ovaries as well as
small bowel.
5 Radiotherapy damage and the recently reported
adhesive peritonitis, which may develop after the combined use of radiotherapy and some chemotherapeutic
agents.
6 Tuberculosis, which is now rarer than in former
years but still occurs and presents grave management
problems to the surgeon when the process of adhesive
peritonitis has developed.
The operation
Closed trauma
If the damage to the bowel has not resulted in opening
the lumen but has simply incised the serosa, allowing
the mucosa to ‘bubble’ through, all that is required is
for the serosa to be resutured over the defect using a
single layer of continuous Vicryl on an atraumatic
round-bodied needle.
Open damage
If the lumen has been entered, the surgeon must determine whether the bowel has been devitalized or not. If
the damage is via a clean cut without crushing of the
edges of the lesion, it may be possible to perform a primary repair. This should be performed in a single layer
apposing the serosa using either a continuous or an
interrupted suturing technique with Vicryl or
Monocryl. It is important not to narrow the bowel
lumen when repairing so the defect should be repaired
transversely and sutures should not be drawn too tightly. The repaired bowel must be examined for patency by
grasping the lumen under the repair between finger and
thumb making allowances for the fact that postopera-
cut end of the appendix with a small forceps. Thus, as
the surgeon begins to draw the purse-string suture
tight, the assistant slips the end of the appendix below
the surface produced by the invaginating edges of the
caecum. The small forceps are then discarded.
Variations in technique
There are many minor variations of this procedure,
including not burying the stump at all.
Retrograde appendicectomy may be necessary when
the tip or part of the length of the organ is involved in
adhesions or not readily accessible, such as in the retrocaecal position. The base is cleared around its circumference and clamped, tied, cut and invaginated as
described above. The remainder of the appendix is then
dissected free from all adhesions. If the surgeon stays
close to the caecum there is a readily found tissue plane
which is often very simply separated, reducing the risk
of entering either the appendix or the caecum. Rarely, it
may be necessary to remove the appendix piecemeal;
this should be avoided as the risk of contamination of
the abdominal cavity is considerable.
If the appendix is inflamed and pus is present in
the peritoneal cavity, the surgeon should carry out
peritoneal lavage with an antiseptic solution, having
first taken bacteriology swabs for culture and drug
sensitivity.
Management of operative injuries of
the intestine
The majority of injuries to bowel are avoidable.
One of the commonest circumstances when bowel is
damaged is when the peritoneum is opened. This may
be due to adhesion of bowel to the parietal peritoneum
or simply due to the fact that the surgeon has picked up
an edge of bowel in the forceps when elevating the peritoneum prior to incision. The simple safeguard of running the fingers between the forceps will reduce this risk
almost to nil.
Other causes include:
1 Lack of experience in handling bowel, particularly
bowel damaged by irradiation or affected by disease
such as carcinoma deposits.
2 An inadequate incision or poor light, which gives
poor vision of the operative field and requires assistants
to retract unnecessarily forcefully to gain access.
3 Unnecessary haste and carelessness in performing
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Suturing the bowel The two ends of the bowel are now
drawn together and repaired in a single layer beginning
at the posterior layer of serosa (Fig. 26.5) and continuing round (Fig. 26.6) to join the initial suture. The
author uses a continuous suture of 2.0 Monocryl on a
round-bodied atraumatic needle. Some authorities
advocate interrupted sutures and others still recommend repair in two layers.
Suturing the mesentery The two edges of the mesentery are now apposed using interrupted Vicryl sutures.
It is important to pick up the peritoneal edges on both
tive oedema may further reduce the diameter of the
lumen.
Nasogastric tube
If the repair is in the proximal part of the small bowel it
is a useful safeguard to ask the anaesthetist to insert a
nasogastric tube during the anaesthetic and maintain it
until satisfactory bowel action returns in the postoperative period.
Resection of a segment of bowel
If the traumatized length of bowel becomes dark due to
loss of blood supply or where there has been extensive
tearing or crushing of the edges, the surgeon must be
prepared to resect the segment. This may be performed
either in the traditional manner described here or using
stapling techniques similar to those described in
Chapter 28. The principles are identical.
Identifying the arterial arcade and resecting the affected segment If the segment of bowel containing the
traumatized area is elevated and transilluminated, the
arterial arcade can be identified. Soft, non-occluding
bowel clamps are then applied so that an adequate vascular supply reaches the proposed resection lines (Fig.
26.4). ‘Crushing’ bowel clamps are then placed at
either end of the segment to be removed and the segment is then resected by cutting along the ‘crushing’
clamps. The small vessels in the mesentery are tied with
2 or 3.0 Vicryl.
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275
Fig. 26.4 Resection of a damaged segment of
small bowel.
Fig. 26.5 Suturing the serosa of the bowel segments.
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The formation of a colostomy
In current practice it is unnecessary that a gynaecological surgeon know how to perform a colostomy, but it
should be standard practice for a gynaecological oncologist. The indications for this procedure are various
and include rectal involvement in ovarian carcinoma,
the occurrence of gross radiotherapy damage in the
pelvis, as part of the management of rectovaginal fistulae, certain cases of diverticulitis, and as a preliminary
manoeuvre prior to an anovulvectomy.
Siting of the stoma
This is a skill which the gynaecological oncology surgeon should learn, but is normally performed by the
stoma therapist who should visit the patient in the preoperative period if a stoma is planned or likely. For
emergency colostomies the surgeon must rely on his
own ability to site the stoma correctly.
Patient preparation
If the colostomy is a planned procedure, the patient
should have the bowel as empty as possible and some
authorities recommend the gut flora should be sterilized using a non-absorbable oral antibiotic.
The bowel should be emptied using a combination
of an oral aperient with or without an enema. High
colonic lavage and extreme purgation with agents such
as magnesium sulphate is not acceptable and simply
produces lassitude and demoralization in the patient.
Clearly, when the colostomy has to be made as an
emergency procedure, bowel preparation cannot be
carried out and the patient should be given intravenous
antibiotics during and following the surgery.
The type of colostomy to be made will depend
mainly on whether it is intended to be temporary or
permanent.
Temporary colostomy
The position of the stoma will depend upon future
surgical requirements. The colostomy should be sited
away from areas where further intervention is considered. For most purposes, a mid-line upper abdominal site is suitable, the left iliac fossa site being used for
a temporary colostomy only when no further surgery is
envisaged in that area.
surfaces of the mesentery and not to take bites which
are so large as to damage the vasculature (Fig. 26.7).
The mesentery must be handled delicately at all times
as it is very easy to traumatize the small vessels, producing a spreading haematoma which may further jeopardize the blood supply to the bowel.
This technique of resection of bowel can be applied
to any length of bowel, both large and small.
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276
Fig. 26.6 Completing the serosal suture.
Fig. 26.7 Apposing the mesenteric edges.
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Opening the stoma The bowel is opened along its
antemesenteric border through a taenia, as this area is
relatively avascular. A stoma bag is immediately applied so that the patient leaves theatre with the colostomy completed and fitted with an appropriate
appliance.
Removal of the bridge The stoma bridge can be removed as soon as serosal adhesions have formed,
usually within 4–5 days.
Reversal of the colostomy The great advantage of the
loop colostomy is the ease with which it can be reversed. All that is required is for the adhesions between
the bowel wall and the abdominal wall to be carefully
dissected free, the bowel closed using a single-layered
closure (made transversely so as not to narrow the
lumen) and the colon reinserted into the abdomen. The
abdominal wall is then closed in layers as described in
Chapter 6.
A permanent colostomy
It will be rare for the gynaecologist to have to make a
The operation
Opening the abdomen Frequently, the abdomen will
be open when the decision to perform a temporary
colostomy is made. However, if it is not, the site of
choice is usually above the umbilicus in the mid-line
(Fig. 26.8). The incision is made transversely, incising
the rectus sheath and separating the muscles so that the
peritoneum is entered in the mid-line.
Forming the loop colostomy The transverse colon is
identified and drawn out of the wound; it is easy to
identify the colon because of the taenia running longitudinally. The greater omentum is seen to extend from
the inferior border of the colon and should be dissected
from the colon over a distance of about 10 cm; small
vessels are easily identified and ligated.
Anchoring the loop The cleared loop of colon is now
drawn out of the wound and a small hole made in the
mesentery through which a bridge is passed so as to
anchor the loop above the surface (Fig. 26.9).
Closing the abdomen The fascia is now drawn together over the rectus muscles so as not to press too tightly
upon the colon and the skin edges are sutured in a
similar manner. It is not usually necessary to suture the
colon to the edges of the stoma.
INTESTINAL TRACT OPERATIONS
277
Fig. 26.8 The site of incision for a temporary transverse
colostomy.
Fig. 26.9 Anchoring the loop of large bowel to the surface.
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vessels in the mesentery are divided and ligated so as to
release a length of bowel which will reach to the stoma
site without tension. The GIA stapling device is now
placed over the loop at right angles to the lumen and fired
(Fig. 26.10). This leaves the distal end of the bowel sealed
with the staples which, having been checked for bleeding, is lowered into the pelvis.
Making the stoma The marked stoma site is now
picked up with a Littlewood’s forceps and by cutting
transversely with the scalpel a perfect circle of skin is
removed, approximatley 3 cm in diameter (Fig. 26.11).
The peritoneum on the stoma side of the abdominal
wound is grasped in a tissue forceps so that it is
not drawn towards the stoma, distorting the intraabdominal opening. The surgeon then places the first
two fingers of his left hand under the stoma site (Fig.
26.12) and elevates the peritoneum and the abdominal
aponeurosis, which he incises with a scalpel or
diathermy, the assistant clipping the layers in turn as
they are cut. The stoma so produced should comfortably admit the first two fingers of the hand.
Exteriorizing the bowel By passing a pair of Babcock’s
tissue forceps through the stoma, the stapled proximal
end of the sigmoid loop is now drawn out of the orifice.
The loop is checked for undue tension, and then the line
of staples is cut off and the edge of the bowel sutured to
the skin (Fig. 26.13). It is unnecessary to suture the
permanent stoma unless he is involved in gynaecological oncology. The optimum site for a permanent stoma
is in the left iliac fossa, away from bony prominences
and fatty folds. The site should be smooth, both when
the patient stands and when she sits.
Patient preparation
The bowel should be prepared as described above.
The operation
Opening the abdomen The abdomen is frequently
opened for another purpose but if not, a lower mid-line
incision will give good access and allow the stoma
appliances to be attached without impinging on the
wound. Occasionally it may be adequate to make a
small transverse incision at the site for the stoma and
pull the sigmoid through it to form stoma.
Choosing the bowel segment The sigmoid colon is usually the site of bowel to be resected; the loop is elevated
and transilluminated. If the sigmoid is not mobile it can
be freed further by incising the avascular peritoneum
lateral to the colon in the paracolic gutter; this releases
and rotates the bowel medially.
Dividing the bowel The authors use the Gastro Intestinal Anastomosis (GIA) stapling device at all times for
this procedure because of its great accuracy and cleanliness. When a suitable segment has been chosen, the small
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278
Fig. 26.10 Dividing large bowel using
the GIA stapling device.
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Closing the abdomen The abdomen is now closed as
described in Chapter 6.
The formation of a loop ileostomy
The authors are increasingly performing a temporary
loop ileostomy in preference to a temporary colostomy.
The reasons are numerous but include the fact that
there is more mobility with the mesentery of the
small bowel and the contents are more fluid, reducing
the risk of anastomosis breakdown. The procedure is
planned as a temporary stoma, but occasionally when
formed for intestinal obstruction in ovarian cancer is
never reversed. The technique is similar to that for a
colostomy.
edges of the aponeurosis and the peritoneum to the
bowel.
Applying the colostomy appliance The stoma bag is
applied in theatre making sure that it does not impinge
on the mid-line incision.
INTESTINAL TRACT OPERATIONS
279
Fig. 26.11 Removing the skin disc at the stoma site.
Fig. 26.12 Incising the abdominal wall fat, musculature and
peritoneum.
Fig. 26.13 Removing the staple line (a) and suturing the edge
to the skin (b).
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